Healthcare Provider Details

I. General information

NPI: 1629435748
Provider Name (Legal Business Name): JON C HANSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 E KIMBALLS LN STE 207
DRAPER UT
84020-5025
US

IV. Provider business mailing address

PO BOX 100253
ATLANTA GA
30384-0253
US

V. Phone/Fax

Practice location:
  • Phone: 801-576-2300
  • Fax: 801-576-2399
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number14260704-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: